Ureteral Cancer Research Articles

Survival outcomes of renal pelvis and ureter cancer in a community-based cancer registry.

e15141 Background: Studies on renal pelvis and ureter cancer are very small and are limited to tertiary care based cancer registry but community cancer registry studies are lacking. Hence we attemp...

Robotic Distal Ureterectomy with Boari Flap Reconstruction for Distal Ureteral Urothelial Cancers: A Single Institutional Pilot Experience

Low-grade urothelial tumors of the distal ureter historically can be managed by open distal ureterectomy and ureteral reimplantation with or without bladder reconstruction. In recent years, the da Vinci surgical robotic system (DSRS) (Intuitive Surgical Inc., Sunnyvale, CA) has being increasingly used to perform complex urologic cancer surgeries. In this article, we report first on two consecutive patients undergoing robotic distal ureterectomy and Boari flap reconstruction (RDUBF) for distal ureteral cancer. Two consecutive patients underwent RDUBF, both with a diagnosis of low-grade papillary neoplasm of a distal ureter at our institution between August 2008 and November 2008. Perioperative parameters were prospectively collected and analyzed following institutional review board approval. Two patients, male and female (age, 70 and 71 years, respectively) were included in the study. In both the patients, RDUBF was completed transperitoneally without the need for open conversion. The operative time, estimated blood loss, time to hospital discharge, and time to stent removal for both patients were 270 and 220 minutes, 25 and 35 mL, and 2 days and 6 weeks, respectively. The percentage change in hematocrit following surgery was within 5% in all patients. There were no postoperative complications in both patients. Final pathology demonstrated low-grade carcinoma pT1NxMx and pTaNxMx papillary urothelial carcinoma with negative margins in both patients. A MAG3 (mercapto-acetyl-tri-glycine) renal scan at 3 months demonstrated prompt drainage in both patients. At a median follow-up of 6 months, the patients were alive with no signs of recurrent or metastatic disease on cystoscopic, cytologic, or radiologic follow-up. RDUBF reconstruction is technically feasible with using DSRS in select patients with distal ureteral cancer without disease recurrence in the short term. A larger cohort, with long-term follow-up, is necessary to validate our results.

Angiosarcoma-like metastatic carcinoma of the liver

Two cases of metastatic carcinoma strikingly simulating angiosarcoma in the liver are described. The first case was a 53-year-old female with cystic liver tumors which were found 22 months after surgery for ureteral cancer. The second case was an 81-year-old female with multiple tumors in the liver and the pancreas, and a post-mortem examination was carried out. She had undergone surgery for skin cancer three years before. Both cases had an angiosarcoma-like appearance macroscopically and microscopically. Immunohistochemically, the tumor cells of both cases were negative for CD31, CD34, and Factor VIII-related antigen and positive for several types of cytokeratin, suggesting that they were not angiosarcomas but carcinomas. Angiosarcoma is the most common sarcoma arising in the liver. Thus, metastatic carcinoma, which resembles angiosarcoma, might be mistaken for angiosarcoma.

集学的治療が奏効し，長期間良好なＱＯＬを維持している尿管癌・肝／リンパ節転移の１例

A 56-year-old man presented with asymptomatic gross hematuria. Computed tomography (CT) scan revealed right hydronephrosis and a slightly enhanced invasive tumor in the right lower ureter, providing a diagnosis of ureteral cancer stage cT3NOM0. The patient underwent minimum incision endoscopic nephrouretectomy, and pathological examination of the resected specimen revealed urothelial carcinoma and squamous cell carcinoma with metastases to right obturator lymph nodes (pT3pN2). Ten months later, CT scan of the abdomen revealed two hepatic metastases. After three courses of combination chemotherapy consisting of gemcitabine and cisplatin (GC), one tumor completely disappeared and another achieved a partial response. The patient underwent radiofrequency ablation (RFA) for the residual followed by GC chemotherapy. However, eighteen months later, CT scan of the abdomen revealed two metastatic foci in other hepatic lesion. The patient underwent RFA again followed by GC chemotherapy and then all hepatic metastases have not revealed enlargement. More than three years after surgery, the patient has achieved a high quality of life.

Upper Urinary Tract Recurrence After Radical Cystectomy for Bladder Cancer—Who is at Risk?

Patients who underwent radical cystectomy for bladder cancer are at risk for upper urinary tract recurrence. We identified subgroups of patients at increased risk for upper urinary tract recurrence. All 1,420 patients who underwent radical cystectomy for bladder cancer at our center between January 1986 and October 2008 were included in the study. Negative frozen sections of the ureteral margins were obtained from all patients. Data analysis included preoperative tumor history, pathological findings of the cystectomy specimen and complete followup. Survival was calculated using the Kaplan-Meier method. Until October 2008, 25 cases of upper urinary tract recurrence were observed. The overall rate of upper urinary tract recurrence at 5, 10 and 15 years was 2.4%, 3.9% and 4.9%, respectively. Of the patients 3 had superficial tumors of the renal pelvis and 22 had invasive upper tract transitional cell carcinoma. Upper urinary tract recurrence did not develop in any patients with nontransitional cell carcinoma. Four risk factors for upper urinary tract recurrence were identified including history of carcinoma in situ (RR 2.3), history of recurrent bladder cancer (RR 2.6), cystectomy for nonmuscle invasive bladder cancer (RR 3.8) and tumor involvement of the distal ureter in the cystectomy specimen (RR 2.7). Patients with transitional cell carcinoma who had none of these risk factors had an upper urinary tract recurrence rate of only 0.8% at 15 years. This rate increased with the number of positive risk factors, ie 8.4% in patients with 1 to 2 risk factors and 13.5% in those with 3 to 4 risk factors. Patients who underwent cystectomy for transitional cell carcinoma and with at least 1 risk factor for upper urinary tract recurrence should have closer followup regimens than those with nontransitional cell carcinoma or without any of these risk factors.

Incidences of Kidney, Pelvis, Ureter, and Bladder Cancer in a Nationwide, Population-based Cancer Registry, Denmark, 1944-2003

To determine changes in the population-based incidence rates, degree of histologic verification, and morphologic distribution of tumors of the kidney, pelvis, and ureter and bladder in both sexes for the duration of 60 years in Denmark. Age-standardized incidence rates in 5-year age and calendar intervals, histologic verification and morphologic distribution were derived from reports to the Danish Cancer Registry. The incidence of kidney tumors increased by 78% among men and 32% among women during the study period; the incidence of pelvis and ureter tumors increased by 1070% and 2785%, respectively, and those of bladder tumors increased by 325% and 195%, respectively. The incidence of Wilms tumor was stable; the incidence of other kidney tumors leveled out during the last 30 years of the period and those of other 2 groups during the last 20 years. The frequency of histologic verification was stable for pelvis and ureter cancers and Wilms tumor and increased for kidney and bladder tumors. Most of the kidney tumors were of epithelial origin and most others were of urothelial origin. The overall incidences of all tumors increased in both sexes during the 60-year period. Some of the increase could be due to improved diagnosis. The recent decline in rates might be due to reduced exposure to risk factors.

Second opinion pathology in tertiary care of patients with urologic malignancies

Objectives The purpose of this study is to evaluate the utility of second opinion pathology in patients who are seen in consultation for urologic malignancy. Methods We retrospectively reviewed the records of all patients who were seen at our institution in consultation for urologic malignancy from August 2002 to April 2008. All available pathologic slides were reviewed by the urologist and pathologist at the time of consultation and compared with the original diagnosis. Discrepant diagnoses were reviewed by at least 2 pathologists. Diagnostic disagreements were graded as minor or major according to the significance of their effect on treatment or prognosis. We report the proportion and types of diagnostic discrepancies and their impact on patient care. Results A total of 264 patients were seen in consultation. Of these, 213 had pathologic material available for review: prostate cancer 117 (55%), bladder cancer 83 (39%), testis cancer 5 (2%), renal pelvis or ureteral cancer 5 (2%), retroperitoneal tumor 2 (1%), and kidney cancer 1 (0.5%). Disagreement with the original diagnosis was found in 22 cases (10%), of which 18 (8%) were classified as major, and 4 (2%) were classified as minor. Interventions avoided or delayed, as a direct result of second opinion pathology, were a prostate biopsy in 1 patient, management of metastatic prostate cancer in 1 patient, partial nephrectomy in 1 patient, management of urothelial carcinoma in situ (CIS) in 1 patient, and radical cystectomy in 5 patients. Interventions recommended or performed were radical prostatectomy in 1 patient, and radical cystectomy in another. Additional pathology from subsequent biopsy or surgery was available in 12 of the 22 patients, and the second opinion pathologic diagnosis was supported in all patients. Conclusions A second opinion review of surgical pathology for urologic malignancy can result in major therapeutic and prognostic changes, which can impact patient care. Our results support the review of all pathology by the urologist and pathologist as part of the consultation in patients with urologic malignancy.

Late recurrence of uterine endometrioid carcinoma in the upper urinary tract

We will present an unusual case of endometrioid carcinoma that recurred in the upper urinary tract, showing an intraluminal spread, 11 years after hysterectomy for uterine corpus cancer. The case is a 72-year-old female who was referred to us for treatment of left ureteral cancer, at first. Nephroureterectomy was performed and histological examination showed endometrioid carcinoma similar to that resected 11 years earlier. A possible pathogenesis of this case will be discussed.

Ureteral cancer first recognized by mechanical ileus due to intestinal metastasis

We report a case of ureteral transitional cell carcinoma (TCC) first recognized because of mechanical ileus due to intestinal metastasis without definitive evidence of hydronephrosis or ureteral mass on plain computed tomography. We believe this to be the first case of ureteral TCC that was first recognized because of mechanical ileus due to small intestinal metastasis.

Two Cases of Endobronchial Metastasis from Rectal or Ureteral Cancer

Two Cases of Endobronchial Metastasis from Rectal or Ureteral Cancer

Incidence of cutaneous sebaceous carcinoma and risk of associated neoplasms

Sebaceous tumors of the skin occurring in association with an internal malignancy characterize Muir-Torre syndrome (MTS), a variant of hereditary nonpolyposis colon cancer (Lynch syndrome). To the authors' knowledge, only limited information exists regarding incidence patterns of sebaceous carcinoma (SC), and no prior study has quantified risks of associated cancers. The authors calculated cutaneous SC incidence rates (IRs) and IR ratios in 9 US Surveillance, Epidemiology, and End Results program registries (1973-2003). Indirectly standardized incidence ratios and 95% confidence intervals (95% CIs) were calculated for subsequent cancers among 2-month survivors of SC and for subsequent SC after other primary cancers. Among 664 cases of cutaneous SC, nearly 90% were diagnosed among whites (IR, 0.11 per 100,000 person-years), with significantly lower IR noted among blacks (IR, 0.04). Whereas eyelid SC IRs demonstrated no sex differences and stabilized in recent years, IRs of noneyelid SC predominated in men and rose steadily over time. Survivors of SC had a 43% (95% CI, 15%-76%) increased risk of subsequent cancer, and risk of SC was elevated by 52% (95% CI, 24%-84%) among survivors of other cancers. Whether before or after SC, the significant excesses of other primary cancers were limited to noneyelid SC. Patterns suggestive of genetic predisposition included >20-fold risks for early-onset (diagnosed in patients aged <50 years) SC associated with colon, pancreatic, ovarian, or uterine corpus cancers, whereas late-onset SC (diagnosed in patients aged > or =50 years) predisposed to ureter cancer. This population-based study of cutaneous SC revealed an association with a spectrum of early-onset cancers consistent with MTS. Etiologic heterogeneity was suggested by differences between eyelid and noneyelid SC in incidence patterns and associated cancer risks.

Use of Ileum as Ureteral Replacement in Urological Reconstruction

We reviewed indications and outcomes in patients undergoing ileal ureter replacement for ureteral reconstruction. Between December 1989 and September 2007, 105 patients underwent ileal ureter replacement, of whom 14 were excluded from study due to incomplete data. The remaining 91 patients (99 renal units) comprised the study cohort. Mean patient age was 46.8 years and mean followup was 36.0 months. Indications for an ileal ureter were stricture following genitourinary surgery in 29 cases (31.9%), radiation induced stricture in 17 (18.7%), nonurological surgery iatrogenic injury in 16 (17.6%) and retroperitoneal fibrosis in 11 (12.1%). Only 4 patients (4.4%) had primary ureteral cancer. Long-term complications included anastomotic stricture in 3 patients (3.3%) and fistula in 6 (6.6%). Serum creatinine decreased or remained stable in 68 patients (74.7%) and hyperchloremic metabolic acidosis developed in 3. No patient complained of excessive urinary mucous production. In 68.1% of patients indications for an ileal ureter included radiation induced stricture or iatrogenic injury. The ileal ureter is a reasonable option for long-term ureteral reconstruction with preserved renal function in carefully selected patients.

Living Unrelated Kidney Transplantation from a Donor with Ureteral Cancer Jeopardizes Survival of Donor and Recipient

To the Editor: Dr. Makoto Mannami performed kidney transplantation from unrelated living donors with renal diseases, including renal cell and ureteral carcinomas between 1993 and 2006. Incidences of organ trafficking were exposed among the patients treated by Dr. Mannami, and as a result, the problem of the so‐called restored kidneys with renal diseases came to light. The Japan Society for Transplantation, the Japanese Urological Society and the Japanese Society of Nephrology formed a special committee to investigate the medical practices of Dr. Mannami and issued a joint statement in May 2007 stating that the medical practices were flawed from both medical and ethical viewpoints. As a result, the following problems became clear: 1Lack of documented informed consent of the donors and recipients. As Dr. Mannami commented in the newspaper, there was no record of explanation about the operation of donors and recipients.2False mentioning in an operation record and flawed operative technique in donors from the standpoint of a cancer operation. Dr. Mannami claimed as follows: All patients/donors agreed to undergo total nephrectomy. The lesions were removed/repaired ex vivo on the back table and then transplanted. All recipients were notified of all possible risks including donor disease recurrence (1Mannami M Mannami R Mitsuhata N et al.Last resort for renal transplant recipients, ‘restored kidneys' from living donors/patients.Am J Transplant. 2008; 8: 811-818Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). However, the above description is clearly falsified. ‘Tumors were removed on the back table’ is incorrect. We investigated the patients' records under the supervision of the Japanese Ministry of Health, Labour and Welfare. According to the operating record of donor/patient, aged 74 (left ureteral cancer; stage pT2), the left kidney was first removed for transplantation by transecting the left proximal ureter in the operating field and not on the back table, and thereafter, the remaining lower ureter with the tumor and part of the bladder were extirpated after the patient was shifted from the lateral to the supine position. This patient died of multiple metastases, including the lymph nodes, liver and lung at 239 days postsurgery. Transection of the ureter must be avoided because of the potential of tumor spill. Even in the traditional nephroureterectomy of ureteral tumors, the ureter as well as the tumor should be transected. The procedure of retaining the ureteral tumor in the donor/patient should be prohibited. The description of consent (p. 812), ‘In all recipients and donors, written consent forms with the patient signature of the operative procedure were obtained’, was also false. We investigated the case records of six donors/patients and interviewed four patients and two patients' families about informed consent under the supervision of the Japanese Ministry of Health, Labour and Welfare. It is necessary for the patients to give documented, informed consent for the donation of kidneys and this donation should be clearly differentiated from the nephrectomy. We found that only one patient provided documented, informed consent for nephrectomy and kidney donation. Three patients gave oral, informed consent and doctors recorded it in the patient case records. Only one patient gave informed oral consent and no record was made. One patient received no explanation in the hospital where the patient underwent donor nephrectomy. Dr. Mannami, himself, said in an interview, ‘I have operated more than 600 kidney transplantation but I have never obtained documented informed consents from any donors and recipients. Those are not really necessary’. The surgical procedures for these eight patients with ureteral cancer were not conducted properly. We have to warn professional urologists, transplant surgeons and physicians that these surgical procedures—transection of the ureter in vivo and the late timing of ligation of renal vessels with no formal documented, informed consent, and carrying out donor nephrectomy for patients with ureteral cancer—are not reasonable.

Papillary urothelial carcinoma in sigmoid neobladder suggesting ‘intraluminal seeding’ from ureter cancer

Papillary urothelial carcinoma in sigmoid neobladder suggesting ‘intraluminal seeding’ from ureter cancer

Continent Orthotopic Ileal Neobladder After Kidney Transplantation in a Patient With Urothelial Cell Carcinoma Associated With Chinese Herb Nephropathy

A 58-year-old man underwent kidney transplantation on November 14, 2002 for end-stage kidney disease after Chinese herb nephropathy. Immunosuppressive therapy was maintained with tacrolimus, mycophenolate mofetil, and methylpredonisolone. He was diagnosed with right ureteral cancer and underwent right nephroureterectomy on December 13, 2003. Then, he underwent left nephroureterectomy for left ureteral cancer on March 5, 2004. Subsequently, he was diagnosed with multiple bladder cancers and carcinoma in situ. On August 31, he underwent radical cystectomy with an orthotopic ileal neobladder (Studer's method). The postoperative course was uneventful. After 3 years follow-up, this patient shows no evidence of recurrence and his serum creatinine level is stable (1.7 mg/dL). The continence is maintained during both day and night; he voids without intermittent self-catheterization. We suggest that an orthotopic ileal neobladder is a safe method of urinary diversion after cystectomy in kidney transplant recipients.

Association Between Colorectal Cancer and Urologic Cancers

Different types of urologic cancers have been associated with colorectal cancer (CRC) in hereditary nonpolyposis CRC, but it is still unknown whether there is an association between urologic cancer and CRC in the general population. We sought to quantify the risk for CRC after urologic cancer and the risk for urologic cancer after CRC in patients without known genetic syndromes. We performed a retrospective cohort analysis of the Surveillance, Epidemiology, and End Results program database from 1973 to 2000. Standard incidence ratios (SIRs) of observed to expected cases of invasive CRC were calculated for each urologic cancer site based on age, sex, ethnicity, and calendar year of diagnosis. Similar analysis was performed to determine the SIRs of urologic cancers in patients with previous CRC. Overall, the risk for CRC was increased among patients with previous ureteral cancer (SIR, 1.80; 95% confidence interval [CI], 1.46-2.20) and renal pelvis cancer (SIR, 1.44; 95% CI, 1.20-1.72). This risk was greatest among patients who received the diagnosis of renal pelvis or ureteral cancer before the age of 60 years. There was a minimal increased risk for subsequent CRC in patients with bladder or renal parenchymal cancer. Overall, the risk for urologic cancer was increased after a diagnosis of CRC (SIR, 1.24; 95% CI, 1.20-1.28), with the highest risk for subsequent renal pelvis and ureteral cancers in patients with a CRC diagnosis before the ages of 50 to 60 years or multiple primary CRCs. Previous renal pelvis and ureteral cancers, particularly when diagnosed at an early age, increase the risk for subsequent CRC. Likewise, a history of CRC, especially in cases with multiple primary tumors, is associated with an increased risk of renal pelvis and ureteral cancers. These findings support a possible common pathogenetic mechanism between CRC and urologic cancers and may have implications for screening guidelines.

Last Resort for Renal Transplant Recipients, ‘Restored Kidneys’ from Living Donors/Patients

Because of the grave shortage of deceased kidney allografts in Japan, we have embarked on a new source of organs, 'Restored kidneys' from living patients. From January 1991 through September 2006, 42 kidneys (eight benign pathology, eight small renal cancers, eight ureteral cancers, six aneurysms, eight severe nephrotic syndrome from four patients and four ureteral stenosis) were obtained from 38 patients/donors after extensive discussion of treatment modalities and risks. All patients/donors agreed to undergo total nephrectomy. The lesions were removed/repaired ex vivo on the back table, then transplanted. All recipients were notified of all possible risks including donor disease recurrence. One, 5 and 10-year patient survival rates of restored transplant patients were 92.9%, 79.3% and 63.8%, respectively. One, 5 and 10-year graft survival rates of restored kidney transplant patients were 78.6%, 51.8% and 42.7%, respectively. There were no recurrences of small renal cell carcinomas. There was one recurrence of ureteral cancer in the transplanted kidney 15 months after operation. In countries where deceased donors are scarce, such as Japan, the restored kidneys can be a last resort for renal allografts.

Independent predictors of metachronous bladder transitional cell carcinoma (TCC) after nephroureterectomy for TCC of the upper urinary tract

To identify the prognostic factors predictive of metachronous bladder transitional cell carcinoma (TCC) in a multi-institutional dataset of patients who had undergone nephroureterectomy (NU) for nonmetastatic upper urinary tract (UUT) TCC. The clinical and pathological data of 231 patients who had had NU for UUT-TCC from 1989 to 2005 in three European centres were collected retrospectively, and analysed for clinical and pathological variables. The median follow-up was 38 months; during the follow-up, bladder TCC was detected in 109 patients (47.2%), and was significantly more common in patients who had UUT-TCC after previous bladder TCC (P < 0.001), in those with ureteric cancer (P = 0.022), and in those with pT2 UUT-TCC (P = 0.017). On multivariate analysis, a previous history of bladder TCC was the only independent predictor of metachronous bladder TCC (hazard ratio 2.825; P < 0.001). The 5-year probability of being free from metachronous bladder TCC was 45.5%. A history of bladder TCC (P < 0.001) and UUT tumour site (P = 0.01) were significantly associated with the probability of bladder recurrence-free survival. On multivariate analyses, a previous history of bladder TCC (hazard ratio 2.226; P < 0.001) and the presence of ureteric TCC (1.562; P = 0.036) were independent predictors of the probabilities of being free from metachronous bladder TCC. In this multi-institutional study of patients who had had NU for UUT-TCC, a history of bladder TCC was the only independent predictor of metachronous bladder TCC, while both a history of bladder TCC and the presence of ureteric tumours were predictive of the probabilities of being free from metachronous bladder TCC.

腎盂尿管癌におけるp53, Ki-67, E-cadherin, β-catenin の免疫組織学的検討

We reviewed prognosis and bladder recurrence of 31 patients with renal pelvic and ureteral cancer concerning clinicopathological and immunohistochemical factors. The patients consisted of 19 males and 12 females. The median age was 69 years, ranging from 43 to 84 years. Median follow-up period was 79 months. Immunohistochemistry for p53, Ki-67, E-cadherin and beta-catenin was performed on sections from tumor tissue. The overall 5-year cause-specific survival rate was 77.4%. Univariate analysis indicated tumor number, grade, infiltrating pattern, lymphatic involvement to be significant prognostic factors. Moreover, multivariate analysis with Cox's proportional hazard model revealed tumor number and lymphatic involvement to be independent prognostic factors for cause-specific survival rate. The overall 5-year bladder recurrence free rate was 60.9%. Univariate analysis revealed expression of E-cadherin to be a significant factor for bladder recurrence free rate.

Completeness and correctness of registration of renal pelvic and ureteral cancer in the Swedish Cancer Registry

To study the completeness and correctness of the Swedish Cancer Registry (SCR) for renal pelvic and ureteral carcinomas diagnosed in western Sweden. We performed a retrospective clinical and histopathological study of 939 patients in the SCR with a diagnosis of a renal pelvic or ureteral carcinoma between 1971 and 1998 and of 54 patients with a diagnosis of tumors in multiple locations in the urinary tract. In addition, we reviewed our earlier bladder cancer studies to assess whether patients with upper urinary tract tumors had been notified to the SCR. There were 68 false-positive patients (7.2%) out of 939 in the SCR. The commonest diagnoses were other urological malignancies (n=46) and no malignancy at all (n=15). There were five false-positives (9.3%) out of 54 patients in the file with tumors in multiple locations. Twenty-eight patients with renal pelvic or ureteral carcinoma were identified in our earlier studies but not found in the SCR. Most discrepancies were attributable to inadequate or missing notification by the urologist and registration errors. The completeness and correctness of the registration of renal pelvic and ureteral carcinomas are unsatisfactory but in line with registries for some other primary sites. The notification of upper urinary tract tumors among patients with a history of bladder cancer was poor, in particular in patients not treated with surgery. Improved communication between reporting sources and the registry is needed. Clinical and histopathological reviews seem necessary in studies based on the SCR.